COPD- 98% O2 sat?

How nice to have an online community like this!
Anyway, I worked yesterday (my 3rd.week! I'm surviving) pm shift at the snf. We had a lady who has COPD & complained to me at around 5.30 pm that she can't breath. Checked O2 sat...it was 98% on 2L...I checked the MAR & the MD's order is to keep O2 sat at 90-92%...We put down O2 at .5L & asked for an order for nebulizer (she has some wheezing)...After 30 mins O2 Sat went down to 96%, still difficulty breathing but not as labored as before..I called MD again, & ordered routine neb q 6hrs for shortness of breath...Now my question is, do u still give nebulizer treatment to a COPD pt. routinely even when there is no wheezing? Please I need some advise. Btw, when I went home at 11.30pm, she said she's feeling better & O2 sat still between 94-95%. What else should I have done? I am so poor in assessment. I know this is tough being a new graduate/new nurse. Thank you so much in advance for your response.

How nice to have an online community like this!
Anyway, I worked yesterday (my 3rd.week! I'm surviving) pm shift at the snf. We had a lady who has COPD & complained to me at around 5.30 pm that she can't breath. Checked O2 sat...it was 98% on 2L...I checked the MAR & the MD's order is to keep O2 sat at 90-92%...We put down O2 at .5L & asked for an order for nebulizer (she has some wheezing)...After 30 mins O2 Sat went down to 96%, still difficulty breathing but not as labored as before..I called MD again, & ordered routine neb q 6hrs for shortness of breath...Now my question is, do u still give nebulizer treatment to a COPD pt. routinely even when there is no wheezing? Please I need some advise. Btw, when I went home at 11.30pm, she said she's feeling better & O2 sat still between 94-95%. What else should I have done? I am so poor in assessment. I know this is tough being a new graduate/new nurse. Thank you so much in advance for your response.

Ok....You are doing a good job! Don't be so hard on yourself!!

Now...not all COPD patients are CO2 retainers. When the order reads "Keep Sat 90-92%" means you may titrate the O2 up to maintain that Sat........ You don't have to decrease the O2 to get to that Sat(90-92) especially when the patient is short of breath. You can have a good O2 Sat and still feel SOB and you don't have to wait until you have a low O2 Sat to treat the patient. The SOB can be causes by sewlling or irritation to the airways as well as bronchospasm. Depending on the meds in the neb treats the underlying causes of the SOB which are sometime given with steroid to decrease any swelling.

The order stated to give the nebs for SOB. it did say give only if patient wheezing....So if the patient wasn't wheezing but SOB you would still give them......but...... if the patient wasn't SOB would you still give them?
OR did the MD mean them to be PRN for SOB.

I would have left the O2 at the 2 liters and given the nebs.....in the end...she felt better.......Good job.

You did the right thing by turning down the O2 and the nebs helped to dilate the pulmonary arteries which allow for more gas exchange. The fact that the lady felt better with less oxygen may mean that she is a CO2 reatainer. The pathophys behind COPD is that the central nervous system is less sensitive to CO2 levels. The peripheral chemoreceptors begin to somewhat regulate the respiratory drive but happen to be more sensitive to O2. The ladies body may have said we have too much oxyegen we don't need to breath which may have increased her CO2 leading to her feeling SOB. Too much O2 for COPD is a common mistake but congrats for saving a life and avoiding a trip to the ICU.

The pathophys behind COPD is that the central nervous system is less sensitive to CO2 levels. The peripheral chemoreceptors begin to somewhat regulate the respiratory drive but happen to be more sensitive to O2. The ladies body may have said we have too much oxyegen we don't need to breath which may have increased her CO2 leading to her feeling SOB. Too much O2 for COPD is a common mistake but congrats for saving a life and avoiding a trip to the ICU.

Guidelines for COPD have changed dramatically since the 1970s and we now have enough EBM to dispute the "hypoxic drive" theory.

The ATS/ERS have also reworded their guidelines to reflect these changes and have also change their wording to now state:

The goal is to prevent tissue hypoxia by maintaining an arterial oxygen saturation (SaO2) at >90%.

Note that it states SaO2 and not SpO2. SpO2 is an excellent monitor but one must also be away of other things that can make the SpO2 inaccurate this includes smoking and certain medications.

Prevention of tissue hypoxia supercedes CO2 retention concerns.

Withdrawal of oxygen because of improved [FONT=TimesNewRomanPS-ItalicMT]PaO2 in patients with a documented need

for oxygen may be detrimental.

Too many patients have been needleesly harmed by the misinformation passed along from the days of "never more than 2 L or greater than 88% SpO2 will knock out the hypoxic drive of a COPD patient without taking any other factors into consideration.

The difference in the disease processes for what constitutes COPD also makes "wheezing" not always a common factor which is why doctors now write "shortness of breath". The mechanism of some medications such as Atrovent should also be understood. For these reasons Asthma and COPD now are taken into consideration separately.

Also review the many other reasons that can cause shortness of breath such as low BP, fever, glucose irregularities, pain, irregular heartbeats and infection. Many of these things can be ruled out with a simple but thorough assessment but at least you will have covered all the bases rather than becoming distracted by one symptom.

You did the right thing by turning down the O2 and the nebs helped to dilate the pulmonary arteries which allow for more gas exchange. The fact that the lady felt better with less oxygen may mean that she is a CO2 reatainer. The pathophys behind COPD is that the central nervous system is less sensitive to CO2 levels. The peripheral chemoreceptors begin to somewhat regulate the respiratory drive but happen to be more sensitive to O2. The ladies body may have said we have too much oxyegen we don't need to breath which may have increased her CO2 leading to her feeling SOB. Too much O2 for COPD is a common mistake but congrats for saving a life and avoiding a trip to the ICU.

yes n that/

May 23, '11

Joined: Dec '04; Posts: 6,653; Likes: 23,216

I'll grant that "thinking has changed" regarding CO2 retainers and oxygen. However, my empirical experience with hospice - thus very end stage - lungers is that they will often c/o dyspnea and look restless and anxious when their pulse ox climbs too high and have gotten relief by reducing the oxygen a bit.

In this case, however, it's harder to tell what worked, since she was also wheezing - the neb tx was more likely responsible for her improvement.

In hospice we use a touch of morphine and anxiolytic to manage symptoms of respiratory distress when people are otherwise stable (and sometimes when they are not). It is important to remember that dyspnea makes people particularly anxious and that sometimes it is necessary to treat that anxiety before we can manage dyspnea very well. I know this is specific to hospice, but it can be helpful even to use non-pharmacologic anxiety management in COPD.

My apologies I meant pulmonary airways...thanks for providing such great literature to make this "evidence based practice".

Extensive research went into those guidelines which are updated frequently just like the AHA does for cardiac issues.

Many don't realize that the treatment for COPD and Asthma is an international collaboration. If you note for these guidelines the American Thoracic Society (ATS) and the European Respiratory Society worked closely together. Canada also has a huge Society addressing COPD and Asthma as does New Zealand/Australia.

There are also other countries with their own Associations and they present their research with the others at international conferences.

Just like the AHA with its journal Circulation, each of these societies have professional journals to keep others up to date on the advances in pulmonary medicine. Those who like to state up to date on what other countries are doing may be envious in knowing that some technology and meds may not become available in the U.S. for many years.

They also address many other pulmonary diseases and will work with other associations such as the AHA when issues overlap or guidelines pertain to other disease processes which in some cases it is hard to treat just one disease process without addressing the other.

I'll grant that "thinking has changed" regarding CO2 retainers and oxygen. However, my empirical experience with hospice - thus very end stage - lungers is that they will often c/o dyspnea and look restless and anxious when their pulse ox climbs too high and have gotten relief by reducing the oxygen a bit.

By reducing the oxygen you may also be reducing mentation. When a patient is dying, the number on the pulse ox is not always indicative of what the tissues are receiving. This is similar to when we use ScvO2 monitoring in the ICUs. The SpO2 might be great but the ScvO2 might not be.

In fact, when we do have patients in hospice or with comfort care orders, we do not number watch. We watch for signs of discomfort and will usually treat that through other means of pharmaceuticals since we know the body is probably no longer able to oxygenate the tissue or organs as a healthy person would.

If the patient is alert enough and wants to remain awake, we may nebulize fentanyl with a breath-actuated nebulizer. This also seems to give them some relief of the dypnea they feel which is difficult to relieve without making them almost unconscious with other medications.